IMMIGRANTS AND

HEALTH CARE IN

CALIFORNIA

Gabrielle Lessard, Esq., and Alvaro M. Huerta, Esq.

National Immigration Law Center

ROAD MAP

Immigrants in California

Eligibility Requirements

Barriers

ROAD MAP

Immigrants in California

Eligibility Requirements

Barriers

Immigrants in California

Highest Share in US:

10.3 million foreign born (27% of state pop.)

4.8 million naturalized citizens (47% of immigrants)

~2.6 million undocumented (7% of state pop.)

~23% of national undocumented population

Mixed-Status Families

In Families with Citizens:

Half of California children have at least one immigrant parent

90.4% of these kids are citizens

60% of low-income children have an immigrant parent

13% of California children have an undocumented parent

Insurance and Health Care Access

Immigrants are more likely to be uninsured 47% of non-citizens are uninsured, compared to 16% of

U.S. born citizens

71% of undocumented adults are uninsured

But most of the uninsured are citizens (80%)

Immigrants use fewer health care services than U.S. citizens with the same insurance status Per capita, immigrant use of health services costs less

than half the cost for average citizen

ROAD MAP

Immigrants in California

Eligibility Requirements

Barriers

Coverage Options in CA

Covered California – state health insurance marketplace/exchange

Premium tax credits for families earning up to <400% FPL, and cost-sharing reductions for <250% FPL

Medi-Cal expansion – to 138% of federal poverty level (FPL)

Other safety net programs

E.g., federally-qualified health centers (FQHCs), community clinics, migrant health clinics, public hospitals, charity care

Immigration Process

Noncitizens enter the US lawfully:

As immigrants on a path to lawful permanent resident

(LPR) status

As nonimmigrants admitted for a temporary stay

As refugees admitted because they face persecution

due to race, religion, nationality, political opinion, or

membership in a particular social group

Can adjust to LPR status

Asylees are similar to refugees but apply for the status

after entering the US

Undocumented Immigrants

Entered without inspection

Stayed past the expiration of a temporary visa

Deferred Action for Childhood Arrivals

Deferred Action for Childhood Arrivals (DACA)

Undocumented immigrants who arrived in U.S. before

age 16 (“Dreamers”)

Enrolled in or completed education leading to

employment

Continuously present since

June 15, 2007

Federal Benefits Eligibility

In 1996, Congress divided lawfully present immigrants into two categories for federal benefits eligibility purposes:

“qualified” and “not qualified”

Qualified Immigrants can receive federal benefits, but many are barred from receiving federal benefits until they have been in the U.S. for five years

California uses state funds to provide benefits during this ‘five year bar’

Qualified Immigrants

• Lawful Permanent Residents (LPR)

• Refugees

• Asylees

• Certain domestic violence survivors and their family members

• Certain trafficking survivors and their family members

• Iraqi or Afghani special immigrants (worked for US)

More Qualified Immigrants

• Other humanitarian entrants:

• Persons granted withholding of deportation or removal

• Certain conditional entrants (granted before 4/1980)

• Certain Cuban/Haitian entrants

• Humanitarian and Public Interest Parolees

For a full list, see “‘Lawfully Present’ Individuals Eligible under the Affordable

Care Act” at http://nilc.org/document.html?id=809

State Flexibility

Under the “unborn child” option in CHIP, states can

opt to provide prenatal services to pregnant women

regardless of immigration status

States can use their own funds to provide

Medicaid/CHIP to:

Qualified immigrants during the five year bar

People Permanently Residing Under Color of Law

(PRUCOL)

California has exercised all of these options

PRUCOLs

Permanently Residing Under Color of Law - not an immigration status, but a benefit eligibility category (see MC 13 Form – Statement of Citizenship, Alienage, and Immigration Status)

May include persons:

with approved immediate relative visa petition

who filed application for adjustment to LPR status

granted deferred action (including Deferred Action for Childhood Arrivals or DACA)

granted Family Unity status

granted a stay of deportation

who have lived in the US continuously since before Jan. 1, 1972

who are survivors of domestic violence (certain immigrants)

Other persons in the US with the knowledge of DHS whose departure that agency does not contemplate enforcing.

Eligibility for Covered California

Lawfully Present

Qualified

lawfully present immigrants are eligible to purchase health coverage through state health care marketplaces

no five-year bar

exception:

People who received deferred action through DACA are specifically excluded

Lawfully Present Immigrants

• All “qualified” immigrants

• People with permission to stay in the U.S. indefinitely

• temporary protected status (TPS)

• most with deferred action

• Applicants for LPR and certain other statuses

• People with valid nonimmigrant status not in violation of the

terms of their visas

Complete list:

https://www.healthcare.gov/immigration-status-and-the-

marketplace/

Undocumented Immigrants

• Undocumented residents can receive restricted-scope Medi-Cal

Remain eligible for health programs that are available regardless of immigration status (e.g., public health programs)

Hospitals must still provide emergency care regardless of insurance or immigration status

Community health centers can continue to provide non-emergency health care regardless of immigration status

Eligible to be covered by employer-sponsored group health insurance

Insurance companies may offer insurance policies outside the state exchange(s) that are available to undocumented

DACA

Excluded from access to federally-facilitated, partnership, and state-run marketplaces/exchanges

No premium tax credits and cost-sharing reductions

Exempt from the individual mandate

No access to Medicaid and CHIP

California classifies DACA recipients as PRUCOL Can receive Medi-Cal if otherwise eligible

For FAQ on DACA and Access to Health Care see http://nilc.org/acadacafaq.html

CA Programs Available Regardless of Status

Emergency Medi-Cal Prenatal care (Medi-Cal) Access for Infants and

Mothers (AIM) Long-term care Early Breast Cancer Detection

and Breast and Cervical Cancer Treatment

California Children’s Services (CCS)

Healthy Kids (Children’s Health Initiatives)

Health Programs in some counties (Healthy SF)

Community clinics Child Health and Disability

Prevention Program (CHDP) and CHDP “Gateway”

Family PACT Minor consent services Mental health services Regional Center Services Women Infants and

Children (WIC) School lunch and breakfast

ROAD MAP

Immigrants in California

Eligibility Requirements

Barriers

Barriers

Lack of information/misinformation

Concern that receiving benefits or having medical

debt will interfere with ability to adjust status

(“public charge”)

Fears about jeopardizing family members

Belief that benefits will need to be repaid

Confusion about eligibility

Problems in application process

Language barriers

Public Charge

A “public charge” is a person considered primarily dependent on the government for subsistence, as demonstrated by:

receipt of public cash assistance for income maintenance or

institutionalization for long-term care at government expense

A person who is found likely to become a public charge may be denied:

Admission to the U.S., or

Lawful permanent resident status

Public charge is not a concern for:

Medical benefits other than long-term care

Other non-cash benefits (e.g., SNAP)

People who are already LPRs

Immigration Enforcement

Information about immigration status may be used only to determine an applicant’s eligibility for health care coverage.

ICE has released a notice stating that information provided in health insurance application process will not be used for civil immigration enforcement

On October 25, 2013, U.S. Immigration and Customs Enforcement (ICE) issued a memo titled “Clarification of Existing Practices Related to Certain Health Care Information,” confirming that immigrant parents can enroll their U.S. citizen children and other eligible family members in health insurance programs under the ACA without triggering immigration enforcement activity.

http://www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf

– ¡Now available in Spanish!

http://www.ice.gov/espanol/factsheets/aca-memoSP.htm

Verification

Citizenship or lawful presence is verified for all

applicants

Status is verified electronically through:

Social Security Administration (SSA) for citizens.

U.S. Citizenship and Immigration Services (USCIS) for

noncitizens via the Systematic Alien Verification for

Entitlements (SAVE) database.

Income is verified electronically by the IRS

If unable to verify status or income electronically, enrollees

have an opportunity to provide other documents by upload,

mail or fax.

Issues

Income, identity or immigration status cannot be

verified electronically

Submit paper documents by upload, mail or fax

SSNs

Only individuals who are applying for benefits are

required to provide their immigration/citizenship status.

The Social Security Number (SSN) of a non-applicant

may be requested to electronically verify household

income.

A non-applicant can be required to provide an SSN

only if that person is:

a primary tax filer,

who has an SSN, and

is applying for tax credits.

Key Issues for Mixed-Status Families

• Undocumented people may apply for coverage on

behalf of their dependent family members

Applications should distinguish between applicants (e.g., U.S.

citizen child) & non-applicants (e.g., undocumented parent)

Non-applicants are not required to provide their immigration

status

Non-applicants without SSNs cannot be required to provide one

Never provide an SSN unless officially issued by the Social Security

Administration

Individual Taxpayer Identification Numbers (ITINs) should not be used

Information provided on an application may be used ONLY to

determine eligibility for health insurance.

30

SSN Questions

Some lawfully present immigrants

don’t have SSNs

Request for ITIN

• ITINs should be used for paying taxes only

• The IRS cannot do electronic verification of income with an ITIN

• Select “not eligible for SSN”

• Naturalized

citizens need to

provide proof of

status

Many no longer

have documents

Naturalized Citizens

Immigration Documents List

• No “other” option

• Selection of

document

triggers

request for

additional

information:

A number,

card

number,

expiration

date

• Unable to proceed without completing required information

Language Access

Website is also available in Spanish https://www.coveredca.com/espanol/

Paper application is available in 11 languages, plus English

Fact sheets are available in 12 languages , plus English

Arabic, Armenian, Chinese, Farsi, Hmong, Khmer, Korean, Lao, Russian, Spanish, Tagalog, and Vietnamese

https://www.coveredca.com/fact-sheets/

Language Access

Almost 20% of Californians speak English “less than very well”

About 16.6% of Covered California enrollees identified their primary

language as other than English

2008-2012 American Community Survey 5-Year

Estimates

Covered California

Enrollment Through Feb.

28

(~35,000,000 (~804,000)

Language spoken at

home Speak English less than

"very well"

Spanish 28.60% 13.10% Spanish 8.20% Asian and Pacific

Islander languages 9.60% 4.70%

Asian and Pacific

Islander Languages 8.10%

Other Indo-European

languages 4.40% 1.40%

Indo-European

Languages 0.20%

English

83.40%

Consumer Health Care Resources

Stuck?

Contact the Health Consumer Alliance:

www.healthconsumer.org

Direct access to Covered California

NATIONAL IMMIGRATION LAW CENTER: WWW.NILC.ORG NATIONAL COUNCIL OF LA RAZA: WWW.NCLR.ORG NATIONAL HEALTH LAW PROGRAM: WWW.HEALTHLAW.ORG CENTER ON BUDGET AND POLICY PRIORITIES: WWW.CBPP.ORG CALIFORNIA IMMIGRANT POLICY CENTER: WWW.CAIMMIGRANT.ORG

Resources on Immigrants and Health Care

QUESTIONS?

Visit www.nilc.org/health

Contact Alvaro at huerta@nilc.org

Contact Gabrielle at lessard@nilc.org

National Immigration Law Center

Our mission is to defend & advance the rights & opportunities of low-income immigrants and their family members.

We envision a U.S. society in which all people - regardless of their race, gender, immigration or economic status - are treated equally, fairly, and humanely, have equal access to justice, education, government resources and economic opportunities, and are able to achieve their full potential as human beings.